Challenging behaviour in HIV services

'Challenging behaviour' is a label, and one that is often misused in the context of mental health. Using a profile, this article identifies a number of behaviours that may challenge service. Peter has HIV and has developed a related opportunistic illness, affecting brain function. The author stresses the importance of person-centred care, urging providers to audit their services and evaluate the requirement for alterations to assessment documentation to meet the changing needs of individuals, families and children living with HIV/AIDS.

Index finger lengthening by gradual distraction and bone grafting

We present the case of an 18-year-old woman with a shortened right index finger. The digit was stabilized and lengthened a total of 18 mm by external fixation and iliac bone grafting. A distal interphalangeal fixed flexion deformity of 60 degrees was corrected with external fixation and intermedullary wiring.

Effect of compounds with antibacterial activities in human milk on respiratory syncytial virus and cytomegalovirus in vitro

The effect of some antibacterial compounds present in human milk were tested for antiviral activity against respiratory syncytial virus, Semliki Forest virus and cytomegalovirus. These included the gangliosides GM1, GM2 and GM3, sialyl-lactose, lactoferrin and chondroitin sulphate A, B and C, which were all tested for their ability to inhibit the viruses in cell culture. Of the compounds tested, only the ganglioside GM2, chondroitin sulphate B and lactoferrin inhibited the absorption and growth of respiratory syncytial virus in cell culture, and none inhibited the growth of Semliki Forest virus, indicating that lipid antiviral activity was not associated with any of the gangliosides. While the concentrations of these two compounds required to inhibit respiratory syncytial virus were in excess of those present in human milk, sialyl-lactose concentrations similar to those present in human milk increased the growth of cytomegalovirus. Lactoferrin was confirmed as inhibiting both respiratory syncytial virus and cytomegalovirus growth in culture even when used at lower concentrations than those present in human milk. The antiviral activities of GM2, chondroitin sulphate B and lactoferrin were tested when added to an infant formula. Lactoferrin continued to have antiviral activity against cytomegalovirus, but a lower activity against respiratory syncytial virus; ganglioside GM2 and chondroitin sulphate B still maintained antiviral activity against respiratory syncytial virus.

After-the-fact strategies Mexican Americans use to prevent HIV and STDs

Hispanics make up less than 10% of the U.S. population but account for 83,923 (17%) of all U.S AIDS cases and are disproportionately affected by sexually transmitted diseases (STDs). Nurses have a mandate to provide culturally competent care, but to do so, they must understand what their clients' needs are and how best to deliver nursing care. A key finding of this exploratory focus group study with newly immigrated Mexican Americans in North Carolina was that respondents were actively striving to prevent HIV or STDs. Their preventive practices for both HIV and STDs centered around a "gonorrhea model" of prevention and casual transmission. The emphasis was not on the biomedical model of transmission or prevention (condoms use). The findings also suggested that the level of counseling for prevention needs to be targeted differently for men than for women.

The effects of therapeutic touch on patients with osteoarthritis of the knee

BACKGROUND

The purpose of this study was to determine if therapeutic touch, an alternative medicine modality, is effective in the treatment of osteoarthritis of the knee.

METHODS

A single-blinded randomized control trial was conducted in a family practice center of a community hospital family practice residency program in Pennsylvania. The patients were between the ages of 40 and 80, had been given a diagnosis of osteoarthritis of at least one knee, had not had knee replacement, and had no other connective tissue disease. The patients were randomized to therapeutic touch, mock therapeutic touch, or standard care. The main outcome measures were pain and its impact, general well-being, and health status measured by standardized, validated instruments, as well as the qualitative measurement of a Depth interview.

RESULTS

Twenty-five patients completed the study. The treatment group had significantly decreased pain and improved function as compared with the placebo and control groups. The qualitative Depth interview confirmed this result.

CONCLUSION

Despite the small numbers, significant differences were found in improvement in function and pain for patients receiving therapeutic touch. A larger study is needed to confirm these results. Alternative therapies can neither be accepted nor rejected without being subjected to the scientific method.

Topotecan for the treatment of advanced epithelial ovarian cancer: an open-label phase II study in patients treated after prior chemotherapy that contained cisplatin or carboplatin and paclitaxel

PURPOSE

Topotecan, a topoisomerase I inhibitor, was evaluated in a multicenter, phase II study of women with epithelial ovarian carcinoma who relapsed after one or two prior regimens that included platinum and paclitaxel.

PATIENTS AND METHODS

Topotecan 1.5 mg/m2 daily was administered as a 30-minute infusion for 5 consecutive days on a 21-day cycle. Eligibility criteria included bidimensionally measurable disease, Eastern Cooperative Oncology Group performance status of 2 or less, and adequate bone marrow, liver, and renal function. Efficacy was assessed by independent radiologic review.

RESULTS

One hundred thirty-nine patients were treated; 81% were platinum resistant. Sixty-two patients had received one prior regimen and 77 patients had received two prior regimens. Nine patients were not assessable for response; however, all patients were included in the response analysis. The overall response rate was 13.7%; 12.4% in platinum-resistant and 19.2% in platinum-sensitive patients. Stable disease lasted at least 8 weeks in 27.3% of the patients. The median duration of response and time to progression were 18.1 and 12.1 weeks, respectively. The median survival was 47.0 weeks. Grade 4 neutropenia occurred in 82% of the patients (34% of the courses) and thrombocytopenia in 30% of the patients (9% of the courses). Infectious complications occurred in 6% of the courses. Nonhematologic toxicities were mild. There were no drug-related toxic deaths.

CONCLUSION

As a single agent, topotecan has modest activity in women with advanced epithelial ovarian carcinoma who have progressed or not responded after one or two prior regimens with platinum and paclitaxel. Further investigation of combination regimens is indicated in the primary therapy for ovarian cancer based on the mechanism of action and tolerability.

Rectally administered misoprostol for the treatment of postpartum hemorrhage unresponsive to oxytocin and ergometrine: a descriptive study

OBJECTIVE

To investigate whether rectally administered misoprostol is an effective treatment for postpartum hemorrhage unresponsive to conventional first-line management.

METHODS

We studied 14 women with postpartum hemorrhage unresponsive to oxytocin and ergometrine (n = 10) or, when ergometrine was contraindicated, oxytocin alone (n = 4). While awaiting carboprost, misoprostol 1000 microg (five tablets) was administered rectally.

RESULTS

In all 14 women, the hemorrhage was controlled, and sustained uterine contraction produced within three minutes of administration of misoprostol.

CONCLUSION

Misoprostol appears to be absorbed effectively from rectal as well as oral and vaginal mucosa. Rectally administered misoprostol appears to be an effective treatment for postpartum hemorrhage unresponsive to oxytocin and ergometrine; therefore, it might be an alternative to parenteral prostaglandins or at least minimize the number of women requiring this invasive treatment. Given that it is an inexpensive and stable drug, misoprostol has considerable potential to reduce maternal mortality from postpartum hemorrhage in developing countries.

Exercise-based rehabilitation improves skeletal muscle capacity, exercise tolerance, and quality of life in both women and men with chronic heart failure

BACKGROUND

Data of training effects in chronic heart failure patients are based on findings in men. The purpose of this study was to compare the effects of skeletal muscle endurance training between men and women with chronic heart failure.

METHODS AND RESULTS

Twelve consecutive men (mean [+/- SD] age 58 +/- 9 years, left ventricular ejection fraction 29 +/- 9%) and 12 women (60 +/- 10 years, left ventricular ejection fraction 28 +/- 7%) with moderate, chronic heart failure stratified according to age and inclusion criteria were investigated at baseline and after 8 weeks of knee extensor endurance training. The activity of skeletal muscle citrate synthase and resting heart rate were similar in men and women at baseline and with training improved (P < .0001) similarly in both genders. Peak work rate (P < .0001), peak oxygen uptake (P < .001) and muscle strength (P < .05) at baseline were higher in men than in women. Training improved peak work rate (P < .0001) and muscle strength (P < .0001) similarly in both genders, while improvement in peak oxygen uptake was better in women (P < .001). The distance ambulated during 6 minutes was similar in both genders at baseline and increased after training more in men (P < .004). The overall and physical Sickness Impact Profile indicated similarly reduced health-related quality of life in men and women, while worse psychosocial quality of life was observed in men (P < .05). Both genders improved after exercise training in the overall, physical, and psychosocial Sickness Impact Profile (P < .01).

CONCLUSIONS

Exercise-based rehabilitation improves skeletal muscle capacity, exercise tolerance, and the health-related quality of life in women as well as in men with moderate, chronic heart failure.

The increasing efficacy of breast cancer treatment

Breast cancer is the commonest malignancy in women and although identification of this multi-system disease has increased, the survival rates have not dramatically altered over the past four decades. Optimium treatment of patients with breast cancer is a subject of great debate and traditionally may be divided into surgery, radiotherapy, chemotherapy and hormone manipulation. Halsted's radical mastectomy, although initially superseded by more mutilating surgery involving removal of tumour, breast, pectoral muscles and axillary contents, has given way to more conservative surgery and breast conservation, so now removal of the tumour with a marginal of healthy tissue is possible. Additional loco-regional radiotherapy has added to the increasing number of treatment options available to both doctor and patient. Systemic adjuvant therapy, primarily hormonal therapy, is used with the aim of decreasing the incidence of recurrence and distant tumour development. Through the process of randomized controlled trials these new therapeutic treatments have shown to be effective in the treatment of locoregional disease. Surgery in patients with advanced systemic disease is limited, however radiotherapy is of considerable importance and can be used to treat or palliate sites of metastases. In recent years trials have assessed chemotherapeutic regimens. However, limited number of patients and adequate randomization have hindered the confident acceptance of these results. Cyclophosphamide, methotrexate and 5 fluorouracil still remain the standard chemotherapeutic regimen, however many new drugs are currently undergoing trials and these or combinations of these may prove to be of future clinical use. Dramatic advances in cell and molecular biology have allowed the development of novel breast cancer therapies. Specific oncogenes and loss of tumour suppressor genes have been associated with decrease patient survival, with the presence of lymph node metastases and with decreased relapse free survival. Growth factor receptor blockers and tyrosine kinase inhibitors may be developed to specifically eradicate breast cancer cells. Immunotherapy and gene therapy may produce effective therapies. Trials utilizing cytokines and trials increasing the immunogenicity of tumours have already reported promising results. Surgery, chemotherapy, radiotherapy and hormone manipulation are the major treatment arms of breast cancer therapy. However, breast cancer still accounts for 20 percent of all female cancer deaths and the overall survival of patients has remained relatively static over the past forty years. From our increasing understanding of the pathological processes involved in the development and spread of breast cancer, new pharmaceutical, immunological and gene therapies may dramatically increase the cure rate of this serious disease.

Skeletal muscle endurance training improves peripheral oxidative capacity, exercise tolerance, and health-related quality of life in women with chronic congestive heart failure secondary to either ischemic cardiomyopathy or idiopathic dilated cardiomyopathy

Despite reported benefits of exercise training in men with chronic congestive heart failure (CHF) and in both men and women with coronary artery disease, the effects of training in women with CHF have not been throughly investigated. Therefore, 16 women (62 +/- 10 years [mean +/- SD]) with stable, moderate, chronic CHF (left ventricular ejection fraction 28 +/- 8%) were studied in a randomized crossover trial with 8 weeks of knee extensor endurance training and 8 weeks of nontraining. The effects of the exercise-based rehabilitation were assessed in skeletal muscle metabolic capacity, exercise tolerance, and quality of life. The compliance rate in training was 98% and no adverse events occurred during the study period. Training increased the activity of citrate synthase (44%, p <0.0001) and lactate dehydrogenase (23%, p <0.002) in the trained muscles, and an improved oxidative capacity in relation to the glycolytic capacity (23%, p <0.002) was found. Peak oxygen uptake (14%, p <0.0005) and peak work rate (43%, p <0.0001) during incremental exercise increased, and blood lactate concentration during standardized submaximal exercise and during the recovery phase decreased (17%, p <0.05). The distance ambulated during 6 minutes (p <0.03), and the overall (p <0.01), physical (p <0.05), and psychosocial (p <0.03) health-related quality of life improved. Because the skeletal muscle endurance training improved peripheral oxidative capacity, exercise tolerance, and the health-related quality of life without any adverse events, this mode of training can be recommended for women with chronic heart failure.

Crosstalk of the heart and periphery: skeletal and cardiac muscle as therapeutic targets in heart failure

Heart failure syndrome is initiated as the body's metabolic needs temporarily exceed the pumping capacity of the heart. In most cases, this phenomenon tends to occur during physical exercise. Although not always subjectively recognized, limited exercise capacity remains the clinical hallmark of congestive heart failure. It can be measured objectively as reduced skeletal muscle performance and maximal whole-body oxygen uptake, which are not necessarily explained by central haemodynamic abnormalities. In fact, the initial cardiac condition sets forth a series of peripheral adaptations that are potentially life-saving during acute decompensation but become disadvantageous and symptom-generating in stable heart failure. Inodilator drugs were theoretically ideal to revert the adverse haemodynamic crosstalk between the heart and periphery. However, these drugs failed to improve prognosis in congestive heart failure, whereas drugs that did so showed typically unimpressive haemodynamic effects. Exercise therapy has recently emerged as a safe and effective way to enhance physical performance and subjective well-being in congestive heart failure. A dual therapeutic approach is suggested, consisting of exercise training to improve the periphery and the use of cardioprotective drugs to limit cardiac cellular damage from neurohormonal activation.

The use of mapping in public health and planning health services

The availability of relatively inexpensive, user-friendly geographical information systems, with a steadily extending range of analytic and other facilities, provides a powerful tool for the analysis and display of the increasing number of health-related data sets, and for their greater accessibility. Relationships between several sets of variables can become immediately apparent from a map in a way that is much more difficult to comprehend from a table or description. It is also easy to define ad hoc areas, such as the area adjacent to a possible toxic point source or to a main road, in terms of unit postcodes and Census output areas, to determine standardized rates for mortality and hospital admissions. Apart from the geographical information system itself, the basic requirements are access to relevant data sets including Census data, and to the central postcode directory, which provides grid references for unit postcodes and permits matching of postcoded health events to Census output areas.

Topotecan versus paclitaxel for the treatment of recurrent epithelial ovarian cancer

PURPOSE

Topotecan and paclitaxel were evaluated in a randomized, multicenter study of patients with advanced epithelial ovarian carcinoma who had progressed during or after one platinum-based regimen.

PATIENTS AND METHODS

Patients received either topotecan (1.5 mg/m2) as a 30-minute infusion daily for 5 days every 21 days (n = 112) or paclitaxel (175 mg/m2) infused over 3 hours every 21 days (n = 114). Patients had bidimensionally measurable disease and were assessed for efficacy and toxicity.

RESULTS

Response rate was 23 of 112 (20.5%) in topotecan-treated patients and 15 of 114 (13.2%) in paclitaxel-treated patients (P = .138). Disease stabilization for at least 8 weeks was noted in 30% of patients with topotecan and 33% of patients with paclitaxel. Median durations of response to topotecan and paclitaxel were 32 and 20 weeks, respectively (P = .222) and median times to progression were 23 and 14 weeks, respectively (P = .002). Median survival was 61 weeks for topotecan and 43 weeks for paclitaxel (P = .515). Response rates for topotecan and paclitaxel were 13.3% versus 6.7% (P = .303) in resistant patients (not responded to prior platinum-based therapy or progressed within 6 months of an initial response) and 28.8% versus 20.0% (P = .213) in sensitive patients (progressed > 6 months after response). Neutropenia was significantly more frequent on the topotecan arm 79% versus paclitaxel arm 23% (P < .01). It was short-lasting and noncumulative in both arms. Nonhematologic toxicities were generally mild (grades 1 to 2) for both agents.

CONCLUSION

Topotecan has efficacy at least equivalent to paclitaxel manifested by the higher response rate and significantly longer time to progression.

Improved ventilation and decreased sympathetic stress in chronic heart failure patients following local endurance training with leg muscles

BACKGROUND

Two-legged knee extensor training activates only about half the muscle mass used in traditional cycle ergometer training. With such an exercise model it is possible to achieve a substantial local training effect in spite of a restricted circulatory capacity. The present study sought to investigate the systemic effects of such local training on ventilation and neurohumoral activity in patients with moderate heart failure.

METHODS AND RESULTS

Thirteen male patients with chronic heart failure (age 56 +/- 3 years, EF 28 +/- 3%) performed two-legged knee extensor exercises (about 4 kg of working muscle) for 15 minutes 3 times a week during 8 weeks at 65-75% of peak VO2 of a two-legged kick and were compared to a non-training control group (n = 7, age 62 +/- 3, EF 27 +/- 3%). Before and after the training period VO2, VCO2 and the minute ventilation (1/min) were determined at rest and at submaximal and maximal workloads. Also measured before and after training were two-legged knee extensor peak exercise capacity (W), strength (Nm), a 6-minute walking test (m), quadriceps femoris citrate synthase activity, plasma catecholamines, vasoactive amines and blood lactate during submaximal knee extension exercise, and perceived health-related quality of life. After training, VO2 and VCO2 were reduced at submaximal exercise by 20-30% (P < .01) but were unchanged at peak exercise. With training, the two-legged knee extensor peak exercise capacity increased by 38% (P < .01). The 6-minute walking gait velocity increased by 12% (P < .01) and skeletal muscle citrate synthase activity by 28% (P < .01). Training improved the quality of life (P < .01). After training, VO2 (P < .001), VCO2 (P < .001) and minute ventilation (P < .001) were reduced at the workload corresponding to the maximal workload before training. The ratio minute ventilation/VO2 was reduced (P < .05) after training at the before-training maximal workload. No change was observed in the control group with regard to two-legged peak exercise capacity or peak VO2. Plasma NPY was reduced both at rest and at submaximal exercise by 35% (P < .01), whereas noradrenaline was reduced only during exercise (P < .05).

CONCLUSIONS

Local muscle training is effective in stable chronic heart failure and can improve, in addition to exercise capacity and quality of life, the ventilatory response, and decrease the sympathetic stress.

Efficacy and safety of topotecan in the treatment of advanced ovarian carcinoma

Topotecan (Hycamtin; SmithKline Beecham Pharmaceuticals, Philadelphia, PA) has emerged as a promising new chemotherapy drug for patients with refractory and progressive stage III and IV epithelial ovarian carcinoma. A semisynthetic analog of camptothecin, topotecan exerts its antitumor effects through inhibition of the nuclear enzyme topoisomerase I. Phase I trials found antitumor activity in many topotecan dosing schedules, one of which involved the administration of topotecan daily as a 30-minute infusion for 5 consecutive days, with the cycle repeated every 21 days. With this schedule, the maximum tolerated dose was found to be 1.5 mg/m2/d. In a series of phase II investigations in platinum-resistant ovarian cancer patients, response rates have ranged from 13% to 25%. In addition, a number of patients exhibit prolonged disease stabilization, with overall rates of nonprogression ranging from 37% to 81%. Activity in paclitaxel-resistant patients is also seen, with a multicenter phase II trial showing a response rate of 13% among first-line paclitaxel failures and 14.3% among second-line failures. A phase III trial compared topotecan and paclitaxel as second-line therapies in 226 advanced ovarian cancer patients who had been previously treated with platinum-containing regimens. Preliminary data show that patients treated with topotecan evidenced a higher response rate (23% v 14%), longer response duration (32 weeks v 20 weeks), and significantly longer time to progression (23 weeks v 14 weeks; P = .002). Additional schedules are still being evaluated, with a phase II trial of prolonged infusion of relatively low-dose topotecan over 21 days demonstrating a 37% response rate in 16 patients. All phase II and III trials analyzed thus far indicate that topotecan is well tolerated with an acceptable toxicity profile, with myelosuppression as the dose-limiting toxicity. Hematologic toxicities are predictable, of short duration, and noncumulative. Mild to moderate nonhematologic toxicities are manageable. These findings demonstrate that topotecan is a viable new second-line or salvage treatment for patients with advanced ovarian cancer who are refractory or resistant to prior chemotherapy, including platinum-based agents and/or paclitaxel.